Turning the Corner on the HIV Epidemic: New PHIA Survey Results Announced at CROI 2017 Show Progress in Zimbabwe, Malawi, and Zambia

Newly released findings from national HIV surveys in Zimbabwe, Malawi, and Zambia reveal extraordinary progress in confronting the HIV epidemic. These three countries in Southern Africa have been heavily affected by HIV and now there are encouraging signs that the epidemics are going in the right direction.

The findings, presented on February 16 at the 2017 Conference on Retroviruses and Opportunistic Infections (CROI), are from the PEPFAR-supported Population-based HIV Impact Assessment (PHIA) Project surveys. The surveys are led by each Ministry of Health, with technical assistance from ICAP at Columbia in collaboration with the U.S. Centers for Disease Control and Prevention (CDC). Compared with previous estimates, the PHIA data show that the rate of new infections (incidence) is stabilizing or declining. In addition, more than half of all adults living with HIV, regardless of use of antiretroviral medication, have a suppressed viral load and for those on antiretroviral medication, viral suppression is close to 90 percent. “Taken together, these findings tell a coherent and remarkable story of progress,” said Dr. Jessica Justman, principal investigator. “We can see that Zimbabwe, Malawi, and Zambia are on track to hit the UNAIDS 90-90-90 targets by 2020.”

Understanding the true status of an HIV epidemic rests on accurate measures of HIV prevalence, HIV incidence, and viral load suppression. These critical estimates provide a “report card” on the control of the epidemic and indicate where resources should be channeled to enable continued progress toward the 90-90-90 targets. The PHIA Project provides such information by directly assessing all of these measures through household surveys.

“These results are gratifying evidence that the investment by PEPFAR and other donors, and the efforts of national HIV programs, are paying off. The data from the PHIA surveys provide greater insights on where to focus our collective efforts and resources going forward,” said Dr. Shannon Hader, director of the Division of Global HIV and Tuberculosis at CDC.

In Malawi, Zambia, and Zimbabwe, nationally representative groups of adults and children were recruited in each country in 2015-16. Across the three countries, a total of 76,000 adults and children from 34,000 selected households took part in interviews and provided blood samples for testing. Participants received their HIV test result from a trained counselor during the same visit.

Combined HIV prevalence across the three countries was 12.2 percent among adults ages 15-59 years and 1.4 percent among children ages 0-14 years. Combined HIV incidence among adults was 0.51 percent. The combined prevalence of viral suppression (HIV RNA <1000 c/ml) among all HIV-positive adults, irrespective of knowledge of their HIV status, was 61.8 percent. Achievement of the “first 90 target” across the three countries—i.e., prior knowledge of status among those found to be HIV-positive during the survey—was 70 percent; the “second 90 target”—i.e., the percentage of those aware of their HIV-positive status who report current use of antiretroviral therapy (ART)—was 87 percent; and the “third 90 target”—i.e., the percentage among those who report current ART who had HIV viral suppression—was 89 percent. Less progress has been made toward the 90-90-90 targets among adolescents and young adults compared to older adults.

“These results reflect successful HIV care and treatment programs in each country,” said Dr. Wafaa El-Sadr, Director of ICAP. “Now more than ever, we have to keep our foot on the pedal and push even harder. Targeted testing, especially for adolescents and young adults, and continued expansion of HIV treatment programs and other prevention interventions for all will be critical to achieve ultimate epidemic control.”

A webcast of Dr. Justman’s CROI presentation is available on the CROI website: http://www.croiwebcasts.org/p/2017croi/croi33590

New Findings from the PHIA Project Show Significant Progress Against HIV in Africa

Preliminary results from the PHIA Project are now available for Zimbabwe, Malawi, and Zambia, and the news is excellent. The new data show exceptional progress against the HIV epidemic: rates of new infection are down, the number of people living with HIV is stable, and over half of all people living with HIV are on antiretroviral treatment and virally suppressed.

“The effects of HIV have been far-reaching. But these outcomes affirm that global, country and U.S.-supported HIV efforts have been successful to date, and that strong progress is being made across the entire HIV continuum of care,” said Ambassador Deborah Birx, U.S. Global AIDS Coordinator.

A five-year, multi-country initiative funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through U.S. Centers for Disease Control and Prevention (CDC), and led by ICAP at Columbia University, the PHIA surveys are implemented in collaboration with CDC and the Ministry of Health and other partners in each country. The Project deploys nationally representative household surveys to collect information related to HIV and offer in-home HIV counseling and testing by trained survey staff, with immediate return of results. It also conducts laboratory tests to characterize the HIV epidemic in adults and children and to measure reach and access to prevention, care and treatment services in each country.

The PHIA surveys are also measuring progress toward the UNAIDS 90-90-90 targets: that by 2020, 90 percent of all people living with HIV will know their HIV status, 90 percent of all people diagnosed with HIV will receive treatment, and 90 percent of all people on treatment achieve viral load suppression. This would translate to 73 percent of all HIV-positive people being virally suppressed.

“The Population-based HIV Impact Assessments are a powerful new tool in that they paint the clearest picture to date of the HIV epidemic in several sub-Saharan countries. New findings from Malawi, Zambia, and Zimbabwe validate what we have only been able to previously predict in models – that our global efforts are having a measurable impact in countries with some of the most severe HIV epidemics,” said Dr. Shannon Hader, director of the CDC Division of Global HIV and Tuberculosis.

PHIA and HIV Incidence

PHIA is the first effort to measure the national rate of new HIV infections, or HIV incidence, in the three countries. “The survey was designed to identify the rate of new infections at the national level, as well as to estimate the number of people living with HIV,” said Dr. Jessica Justman, PHIA principal investigator and senior technical director at ICAP. “This information is critically important to determining future resource needs.”

Conducted between October 2015 and August 2016, the first three surveys found that HIV incidence is lower than previously estimated and well below 1 percent in each country. The PHIA data estimate HIV incidence

  • In Zimbabwe as 0.45 percent (ages 15 to 64)
  • In Malawi as 0.37 percent (ages 15 to 64)
  • In Zambia as 0.66 percent (ages 15 to 59)

Compared to the 2003 incidence estimates between 1.3 and 1.5 percent per year for the same three countries, the current rate of new HIV infections has been cut in half during the past 13 years, when effective HIV treatment became available in sub-Saharan Africa, largely through support from PEPFAR.

PHIA and HIV Prevalence

HIV prevalence, or the percentage of people living with HIV, was measured for adults and children, and is similar to 2010 estimates. In addition to validating what has only been predicted previously in models, the surveys also provide new information, including the first measurements of pediatric HIV prevalence in Malawi and Zambia.

  • In Zimbabwe, prevalence among adults ages 15 to 64 is 14.6 percent, and is 1.6 percent among children ages 0 to 14.
  • In Malawi, prevalence among adults ages 15 to 64 is 10.6 percent, and is 1.6 percent among children ages 0 to 14.
  • In Zambia, prevalence among adults ages 15 to 59 is 12.3 percent, and is 1.3 percent among children ages 0 to 14.

These three countries continue to bear a substantial HIV burden, however, with prevalence stabilizing, the PHIA survey results suggest that people living with HIV are living longer thanks to effective and accessible treatment.

PHIA and Viral Load Suppression

The survey also conducted viral load testing for HIV-positive participants, which measures the number of HIV particles in a milliliter of blood to assess the effectiveness of antiretroviral therapy (ART). Viral load suppression (VLS) is a measure of well-controlled HIV infection. Among HIV-positive adults in the first three PHIA countries, prevalence of VLS was:

  • 60.4 percent for those ages 15 to 64 in Zimbabwe
  • 67.6 percent among those ages 15 to 64 in Malawi
  • 59.8 percent among those ages 15 to 59 in Zambia

“It is heartening to see the impressive viral suppression noted in the three countries among those on treatment,” said Dr. Wafaa El-Sadr, director of ICAP. “ Viral suppression is critical for the well-being of people living with HIV and for preventing HIV transmission to others.”

PHIA and 90-90-90

Preliminary PHIA data show that Zimbabwe, Malawi, and Zambia have made great strides in responding to their HIV epidemics. While increases in testing are needed to ensure that all people living with HIV know their status, the PHIA results show that Zimbabwe, Malawi, and Zambia are close to achieving the global targets for, treatment, and VLS.

  • 74.2 percent of PLHIV ages 15 to 64 in Zimbabwe report knowing their status, 86.8 percent of those individuals self-report being on ART, and 86.5 percent of that group are virally suppressed
  • 72.7 percent of PLHIV ages 15 to 64 in Malawi report knowing their status, 88.6 percent of those individuals self-report being on ART, and 90.8 percent of that group are virally suppressed
  • 67.3 percent of PLHIV ages 15 to 59 in Zambia report knowing their status, 85.4 percent of those individuals self-report being on ART, and 89.2 percent of that group are virally suppressed

“These data suggest that, in the areas surveyed, we are making encouraging progress towards global targets for people on HIV treatment and virally suppressed. And although we’ve made great strides, these findings indicate we still need to do more to help ensure people living with HIV are reached with life-saving services,” said Dr. Hader of the CDC.

Looking Forward

The PHIA data offer critical evidence to inform global and national HIV programs and investments in order for progress to be sustained and built upon. However, achieving this will require continued expansion of HIV treatment programs and increased testing for all people, especially men and young women.

“Importantly, the PHIA surveys clearly point to what still needs to be done, who we need to reach, and where we must focus our efforts, in order to build on these achievements,” Ambassador Birx added. “The findings will guide an effective response to the epidemic.”

From Arm to Freezer: PHIA Project Laboratory Network Supports Ambitious HIV Testing Targets

How can a large public health survey in sub-Saharan Africa collect blood samples efficiently? Is it possible to perform sophisticated lab tests in people’s homes? What is the best way to transport samples collected from remote locations? The Population-based HIV Impact Assessment (PHIA) Project, which relies on laboratory testing of blood samples as a core component, is providing answers to these questions. Led by ICAP at Columbia University, the PHIA surveys will assess the HIV epidemic in 13 select countries located primarily in sub-Saharan Africa. Fieldwork is nearly complete in three countries, with ten more national surveys to follow over the next two to three years. The surveys depend on well-trained staff and sufficient laboratory infrastructure to collect, test, and transport blood from individuals in approximately 15,000 households in each country.

Conducted in partnership with ministries of health and the Centers for Disease Control and Prevention (CDC), with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the PHIA Project draws on the expertise of ICAP and its partners for all aspects of its laboratory activities, from facility selection to staff training, laboratory setup, and quality assurance. Critical support in these areas has come from the CDC’s International Laboratory Branch, which builds sustainable laboratory capacity in PEPFAR-supported countries.

Currently, throughout Zimbabwe, Malawi, and Zambia, PHIA survey teams are visiting thousands of households to collect blood samples and perform rapid HIV tests, point-of-care CD4 tests, and in some countries, hepatitis B and syphilis rapid tests. While many other population-based surveys have collected a few drops of blood through a finger prick, the PHIA surveys collect two test tubes of blood from a vein in order to have both whole blood and plasma for testing. Participants receive test results within minutes, in the privacy of their homes. But that is not the final stop for each blood sample.

Quality assurance testing is performed in nearby satellite laboratories to ensure that the initial field test results are accurate. “All HIV-positive samples are retested using the Geenius HIV-1/HIV-2 test in the satellite lab to confirm the results,” says Dr. Herbert Longwe, one of ICAP’s regional lab advisors for the PHIA Project. “We also retest the first 50 of each field worker’s samples and 5 percent of all HIV-negative samples with the same rapid test kits to ensure accurate and trustworthy results.” Dried blood spots are prepared and then plasma and blood cells are separated, steps necessary for further testing. With a targeted “arm-to-freezer” time of less than 24 hours, the samples are then placed in a freezer and sent to a central lab for HIV incidence and HIV viral load testing, as well as for long-term storage.

The last steps in the testing process consist of specialized tests such as viral load testing to measure the quantity of HIV RNA in plasma, HIV incidence assays, DNA-PCR for HIV diagnosis in HIV-exposed infants, assays to detect antiretroviral agents, and HIV drug resistance testing. The two latter tests will be performed after survey completion at labs in several locations, including South Africa and Zimbabwe. The detailed data these additional tests provide can help improve HIV programming at local and national levels by indicating what percentage of people on treatment have achieved viral load suppression, a measure of whether they are on treatment and if treatment is working well.

To handle samples collected in remote locations in Zambia and Tanzania, PHIA teams are using mobile labs to ensure specimen quality. The mobile labs are fully equipped with a centrifuge, refrigerator, a -20⁰ C freezer, and basic supplies. “Mobile labs are an innovative way to handle samples when other labs are not close enough,” says Dr. Yen Pottinger, ICAP’s PHIA senior technical advisor for laboratory.

As part of the focus on high-quality testing and processing of PHIA samples, the PHIA team conducts instrument verification and assay validation to ensure tests are accurate and reliable. Working together, CDC’s International Lab Branch and ICAP monitor the accuracy of the HIV testing in the field and provide ongoing reviews to ensure each and every staff member’s proficiency with the techniques they learned in lab training.

“It was a challenge to create, but the PHIA Project now has a simple, workable quality assurance system in place, and this is one of the most exciting things I’ve seen in my career,” Longwe observes.

HIV viral load results are returned to a health facility of the participant’s choice, where they can consult with a health care provider to interpret the results and gain a greater understanding of their health status. Providing these results to participants is another innovative aspect of the PHIA survey. “Viral load testing is not yet routinely available in many of the survey countries. By returning the results within about eight weeks, the PHIA Project is making it possible for HIV-positive individuals and their doctors to have access to important clinical data to help manage their treatment,” says Pottinger.

PHIA’s complex network of satellite labs is helping the survey teams perform a high volume of HIV tests at the community level—more than 30,000 in Zimbabwe since October, more than 23,000 in Malawi since November, and more than 27,000 in Zambia since March—with accuracy. The systems established by CDC and ICAP also demonstrate the benefits of strong partnerships for a large, complex project, and allow the PHIA Project to pave the way for future surveys to handle blood samples.

Knock Knock Knock: Zimbabwe’s Soundtrack to Understanding HIV

IN NINE LANGUAGES, ICAP’S HIT POP SONG INSPIRES ZIMBABWEANS TO TAKE PART IN A NATIONAL HIV SURVEY

There’s something new spreading through Zimbabwe—and it’s a good thing.

“Knock Knock Knock” is a catchy and up-tempo song, with sunny Afro-jazz beats and a hard-to-forget jingle. More than a hit song on the airwaves of Zimbabwe, it is also an essential tool for public health promotion. (Watch the video, below.)

In Zimbabwe and most African countries, creative arts and music play an important role in promoting public health programs, according to Rosemary Muchengeti, ICAP Communications Officer for the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey. Zimbabwe is the first country to roll out surveys for the PHIA Project, a five-year, multi-country initiative led by ICAP at Columbia University and supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention.

The PHIA Project is measuring the reach and impact of HIV programs in PEPFAR-supported countries by estimating HIV prevalence, incidence, and population viral load in each country. Conducted in close collaboration with ministries of health, the CDC, and local stakeholders, each national survey of about 30,000 adults and children offers household-based HIV counseling and testing with return of results, and asks household members questions about access to preventive care and treatment services. The results of these surveys will guide policy and funding priorities.

Participation in the survey is voluntary, so getting public buy-in is vital for data collection—and “Knock Knock Knock” is one way ZIMPHIA hopes to spread the word.

“We saw the song as tool to communicate about ZIMPHIA through national and community radio stations,” said Muchengeti, who proposed the idea of the song after past success using interactive arts and music for health promotion.

The first step of any health communications campaign is to gauge community interests and preferences, Muchengeti said, to get a sense of public attitudes and beliefs about a particular issue before coming up with a strategy to achieve desired outcomes.

The ICAP team in Zimbabwe worked with project partners including the Ministry of Health and the CDC, as well as community members to develop the lyrics of “Knock Knock Knock,” which conveys its message in English and eight of Zimbabwe’s languages, with the goal of spreading the word far and wide, among old and young.

To lead musical production, ICAP approached Albert Nyathi, a leading Zimbabwean poet, musician and activist. Nyathi then recruited fellow artists who are all well-known in Zimbabwe for their performances in support of various human rights campaigns. Together, these musicians are the voices and faces of “Knock Knock Knock,” communicating the importance of the ZIMPHIA survey to communities. In the dramatic introduction to the song, Nyathi says:

“After a decade of successful scaling up of HIV prevention and treatment efforts in Zimbabwe

Now is the time to assess the effects of HIV in our nation

Now is the right moment to take stock of what has been achieved in confronting the HIV epidemic

In Zimbabwe and define the way forward…”

Played almost daily on the radio in Zimbabwe, the song reaches rural areas as easily as it does city centers. The “Knock Knock Knock” music video is broadcast as a public service announcement on television, and a one-minute jingle version of the song was adapted to be played on ZTV, the country’s one and only national TV channel.

“The ZIMPHIA song is a great example of the creative, collaborative approaches to public health promotion that CDC likes to support,” said Beth Tippett Barr, CDC Country Director, Zimbabwe. “It reflects a strong engagement with our national partners.”

“Knock Knock Knock” has been key to letting the Zimbabwean public know that surveyors would soon come knocking on their doors for the ZIMPHIA survey, according to Muchengeti. But beyond awareness, the song also helps to dispel discomfort and change negative perceptions.

“Many people are understandably reluctant to allow someone to come into their home and draw their blood,” said Jessica Justman, principal investigator for the PHIA Project and ICAP’s senior technical director. “The song makes it easier for people to understand why it’s important for them to take part in ZIMPHIA.”

Unlike other hit songs, the success of “Knock Knock Knock” is not measured by record sales, number of downloads, or YouTube views. In this case, its success is reflected in the nearly 12,000 people who have participated in the ZIMPHIA survey since its launch in October 2015.

“The response has been overwhelming. All age groups are singing along and they love the artists,” Muchengeti said. “The way the song is framed with creativity and with an emphasis on the community is very appealing to the public.”

Zimbabwe’s history of success in responding to the HIV epidemic over the past decade makes it a role model for the other sub-Saharan African countries included in the PHIA Project. Wide participation in the survey will enhance the ability to measure the status of the HIV epidemic and inform the next phase of the global HIV response. And that’s something to sing about.

Watch the video:

BY Michelle Truong,
MPH 2016

Leap of Faith: ZIMPHIA Partners with Religious Leaders in Zimbabwe

Before the PHIA survey teams begin to knock on household doors, community workers visit selected communities, known as enumeration areas, to help community leaders and members understand some of the sensitivities that surround HIV and to strengthen support for the survey. In Zimbabwe, community workers held a recent workshop with members of the Apostolic religious community to make them aware of the project’s potential to improve national health.

Approximately 85 percent of Zimbabweans are Christians, and of those, over one-third are members of the Apostolic Church, a denomination which follows the teachings of Christ’s apostles. In Manicaland Province, where ZIMPHIA survey teams are visiting 1,620 households, about one-quarter of the population is Apostolic. To help encourage full participation of this group, the ZIMPHIA team reached out to the Secretary General of the Union for the Development of Apostolic Churches in Zimbabwe Africa (UDACIZA), the churches’ governing body. As Godfrey Musuka, ICAP’s country representative in Zimbabwe and project director for ZIMPHIA noted, “It’s important for ZIMPHIA to survey a nationally representative ‘slice’ of Zimbabwe, and we asked the Apostolic Church to work together with us on this goal.”

More than 50 Apostolic leaders and bishops attended the workshop, as well as representatives from the Ministry of Health and Child Care and its ZIMPHIA partners: ICAP, the National AIDS Committee, and the Biomedical Research & Training Institute. At the meeting, Dr. Mutsa Mhangara from the Ministry of Health acknowledged the religious leaders’ support, noting that the Ministry of Health “provides health services to all groups in the country and ZIMPHIA provides a unique opportunity to get information to guide service provision and we thank you for accepting this project.”

Ministry of Health representatives gave presentations on the methodology and goals of the survey and explained how the data will be used to improve HIV services throughout Zimbabwe. The presenters also emphasized that the survey is a government program that will inform future health interventions so they can best serve all citizens, including the Apostolic community.

“The Apostolic representatives said that they felt honored to be invited to the meeting because it showed the ZIMPHIA team recognized them as active, important community leaders and provided an opportunity for their voice to be heard,” said Musuka.

The bishops acknowledged HIV as a major health problem in Zimbabwe, and indicated that they were open to any intervention that allowed the government to better understand and respond to the epidemic. The workshop was well-received and included strong statements of support for the survey from church leaders. Rev. Edison Tsvakai, secretary general of UDACIZA, said, “We assure you that we will work together to make this survey a success and we are glad because we will now be able to answer questions when asked about ZIMPHIA by our members.” The UDACIZA endorsed ZIMPHIA, saying “The ZIMPHIA survey is a good project for Zimbabwe and the Apostolic group of churches welcomes it and will participate and support the survey in every way possible.”

Their endorsement and support went beyond the workshop. Shortly after the meeting, the group formed a committee of bishops to assist with community mobilization in Manicaland. The bishops made themselves available to consult with the ZIMPHIA community mobilizers and advise them in case they need help in working with Apostolic Church members.

The ZIMPHIA team’s successful engagement with this religious community will inform community mobilization in other countries as additional PHIA surveys roll out.

There’s an App for That: Using Tablets for PHIA Data Collection

After weeks of training and preparation, PHIA survey teams are on the ground in Zimbabwe and Malawi, equipped with tablet computers and wearing brightly colored t-shirts emblazoned with survey logos. Over the next six months, they will interview adults and children from approximately 15,000 randomly selected households in each country using pre-programmed tablets and portable blood testing equipment.

Tablet technology is a critical part of the PHIA Project, a multi-country initiative to assess the impact of scaled-up national HIV programs on the HIV epidemic in PEPFAR-supported countries. Funded by PEPFAR through the CDC, and implemented in partnership with CDC and key national stakeholders, ICAP plans to launch PHIA surveys in approximately 15 countries in Africa and the Caribbean over the next five years. ICAP, in collaboration with Westat, Inc., a PHIA Project partner with extensive experience collecting data on tablets, developed PHIA-specific apps using Open Data Kit, an open-source software, to collect high-quality data.

To date, teams have used tablets for household listing, a key planning step needed for survey implementation, in Malawi and Zambia. The teams found that it took much less time, only one month, to clean the electronic household listing data in Malawi compared to the six months needed for the paper-based household listing data in Zimbabwe. In addition to a faster time to clean data, the state-of-the-art tablets provide many advantages over paper-based methods, including portability, built-in checks to help reduce errors, and the ability to store all necessary forms in multiple languages.

In Zimbabwe, data collection started with 12 survey teams in October and scaled up to 20 teams in November; they are using 160 tablets programmed with questionnaires and consent forms in three languages created using Open Data Kit. Data collection started in Malawi (160 tablets, three languages) in November and will start in Zambia (260 tablets, eight languages) in December. All team members are trained to conduct interviews using the tablets.

The tablet has pre-programmed skip patterns in the survey questionnaire—meaning the program automatically moves to the most appropriate next question based on participants’ responses to earlier questions—to guide interviewers, and all data collected are uploaded to a central database server. Internet access is not required to complete the forms on the tablets, but only for uploading finalized forms. Portable routers, used to transmit data via Wi-Fi hotspots, maximize connectivity.

In addition, since there are approximately 15 different consents, assents, and permissions for each survey, each tablet includes custom applications that assign the correct consent and permission forms for each participant, based primarily on the age of the individual. Electronic signatures are collected for each form in the tablet, and a scanning app is used to link participant identification numbers with point-of-care testing results from pre-printed barcode labels for blood specimens.

The biomarker testing portion of the survey may include tests for syphilis and hepatitis B in addition to HIV. Survey staff collect blood samples and are guided by a built-in testing algorithm on the tablet that prompts when move on to the next appropriate step after the first HIV rapid test. For example, if the initial HIV test finds the blood sample is reactive, the tablet will instruct the tester to perform a confirmatory HIV test. If the first two HIV test results are discordant, the tablet will prompt the survey staff to conduct a third tie-breaker test.

To be sure, there have been a few technical challenges, such as occasional bugs in the application when revising or correcting forms and the need to hone the survey application within a short testing and review period. However, as the household listing exercises have already demonstrated, the tablets will improve efficiency and quickly provide clean data.

How Close Are We to Beating HIV in Africa?

Harare, Zimbabwe—Due to global efforts to respond to the epidemic, millions of people are receiving HIV treatment and services. But many more still lack access to the care they need. To improve the response, donors and governments require detailed information about the epidemic so they can assess progress and identify future needs. As part of a broader effort to understand the national epidemic in Zimbabwe, the groundbreaking Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey enrolled its first participants in October, with 12 field teams traveling to the northern region of Zimbabwe to start collecting data. It is the first of more than 15 such household-based surveys to be conducted in Africa as part of the PHIA project, which aims to provide a snapshot of the HIV epidemic in each country, representing an important step toward bringing even the most severely affected countries closer to the goal of treating all of those living with HIV and eliminating new infections.

A member of the ZIMPHIA survey team prepares to begin data collection.

Funded by the U.S. Centers for Disease Control and Prevention (CDC) through the President’s Emergency Plan for AIDS Relief (PEPFAR), the PHIA project is led by ICAP at Columbia University. Survey teams will collect information and conduct laboratory tests to estimate the magnitude of the HIV epidemic in adults and children and to measure access to prevention, care and treatment services.

“After more than ten years of global effort to expand access to treatment, there is a great deal of interest in understanding where things stand with the HIV epidemic. ZIMPHIA will allow Zimbabwe to gain a deeper understanding of what has been accomplished and what still needs to be done in the future,” said Jessica Justman, principal investigator and senior technical director at ICAP.

Owen Mugurungi, Director of the AIDS and TB Unit in the Government of Zimbabwe’s Ministry of Health and Child Care, announced the survey’s launch in the Mbire District of Mashonaland Central Province, saying, “ZIMPHIA survey data collection has started, marking a very important milestone in our HIV response efforts as a country.” Mugurungi noted that this survey will be the first of its kind to be conducted in the country. “We are expecting a smooth survey and look forward to high rates of participation by the population,” added Dr. Mugurungi.

ZIMPHIA teams will visit 15,000 randomly selected households across Zimbabwe and administer tablet-based questionnaires to consenting household members. Survey participants receive HIV and syphilis testing and counseling, with immediate return of results, all provided with privacy in each participant’s home. Participants who test positive are referred to their preferred health care facility for treatment.

Zimbabwe’s success in responding to the HIV epidemic has been the result of well-coordinated efforts at the national level. Both the Zimbabwe and U.S. governments are enthusiastic about the ZIMPHIA survey and their continued collaboration supporting the country’s HIV response. Additional resources for the survey are provided by the Government of Zimbabwe and the Global Fund.

“ZIMPHIA, and the PHIA project as a whole, will provide critical evidence that will guide HIV programs over the next decade. This is historic and timely effort will inform the next phase of the global response to the HIV epidemic,” added Wafaa El-Sadr, ICAP director.

ZIMPHIA, a Government of Zimbabwe initiative, is being implemented in partnership with the Biomedical Research and Training Institute of Zimbabwe and Lancet Laboratories. In addition to ICAP, the PHIA project partners include, the African Society for Laboratory Medicine, ICF International, Statistical Center for HIV/AIDS Research and Prevention at the Fred Hutchinson Cancer Center, University of California San Francisco’s Global Health Sciences and Westat, Inc.

Founded in 2003, ICAP at Columbia University supports programs and research that address major health issues such as HIV, malaria, tuberculosis, maternal and child health and non-communicable diseases. ICAP works in collaboration with partners around the world to support high-performing health system strengthening initiatives and implements innovative and sustainable health solutions. ICAP, situated at the Columbia Mailman School of Public Health, works in partnership with governmental and non-governmental organizations across 21 countries.

Data Collection Begins for First PHIA Survey

The groundbreaking Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey enrolled its first participants on October 18th, with 12 ZIMPHIA field teams kicking off data collection in the northern region of Zimbabwe.

ZIMPHIA is part of the PHIA Project, a five-year, multi-country initiative funded by the U.S. Centers for Disease Control and Prevention (CDC) through the President’s Emergency Plan for AIDS Relief (PEPFAR) and led by ICAP at Columbia. The PHIA Project consists of household-based, population surveys that will collect information related to HIV in approximately 15 to 20 African countries. Each survey, beginning with ZIMPHIA, will collect information and conduct laboratory tests in order to estimate the magnitude of the HIV epidemic in adults and children and to measure access to prevention, care and treatment services in each country.

“ZIMPHIA will allow Zimbabwe to gain a deeper understanding of what has been accomplished and what still needs to be done in the future,” said Dr. Jessica Justman, principal investigator and senior technical director at ICAP. “ZIMPHIA, and the PHIA Project as a whole, will provide critical evidence that will guide HIV programs over the next decade.”

Dr. Owen Mugurungi, Director of the AIDS and TB Unit in the Government of Zimbabwe’s Ministry of Health and Child Care, announced the survey’s launch in the Mbire District of Mashonaland Central Province, saying, “ZIMPHIA survey data collection has started, marking a very important milestone in our HIV response efforts as a country.” Dr. Mugurungi noted that this survey will be the first of its kind to be conducted in the country. “We are expecting a smooth survey and look forward to high rates of participation by the population,” added Dr. Mugurungi.

ZIMPHIA teams will visit 15,000 randomly selected households across Zimbabwe and administer tablet-based questionnaires to consenting household members. Survey participants receive HIV and syphilis testing and counseling, with immediate return of results, all provided with privacy in each participant’s home. Participants who test positive are referred to their preferred health care facility for treatment.

Zimbabwe’s success in responding to the HIV epidemic has been the result of well-coordinated efforts at the national level. Both the Zimbabwe and U.S. governments are enthusiastic about the ZIMPHIA survey and their continued collaboration supporting the country’s HIV response. The survey is supported by substantial resources provided by PEPFAR with additional resources provided by the Government of Zimbabwe and the Global Fund.

“This is a historic and timely effort. It will provide critical information to inform the next phase of the global response to the HIV epidemic,” added Wafaa El-Sadr, ICAP director.

ZIMPHIA, a Government of Zimbabwe initiative, is being implemented in partnership the Biomedical Research and Training Institute of Zimbabwe and Lancet Laboratories. The PHIA Project partners include, in addition to ICAP, the African Society for Laboratory Medicine, ICF International, Statistical Center for HIV/AIDS Research and Prevention at the Fred Hutchinson Cancer Center, University of California San Francisco’s Global Health Sciences and Westat, Inc.

Founded in 2003, ICAP at Columbia University supports programs and research that address major health issues such as HIV, malaria, tuberculosis, maternal and child health and non-communicable diseases. ICAP works in collaboration with partners around the world to support high-performing health system strengthening initiatives and implements innovative and sustainable health solutions. ICAP, situated at the Columbia Mailman School of Public Health, works in partnership with governmental and non-governmental organizations across 21 countries.

Major HIV Assessment Launches in Zimbabwe

On September 18th, the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) was formally launched in Harare by Zimbabwe’s Ministry of Health and Child Care, the National AIDS Council, the Ambassador of the Government of the United States of America, and representatives of PEPFAR, CDC, ICAP at Columbia University, and other project partners.

This major initiative will describe the current status of the HIV epidemic in Zimbabwe, with survey teams set to visit approximately 15,000 randomly selected households in order to estimate national HIV incidence, prevalence, and viral load suppression among adults and children. The results of the ZIMPHIA survey will help guide policy and set funding priorities in Zimbabwe in the years to come.

ZIMPHIA teams will offer free and voluntary HIV, CD4, viral load, and syphilis testing to approximately 30,000 adults and children. ZIMPHIA participants will be provided with their HIV test results and post-test counseling, and anyone who tests HIV-positive will be referred to the nearest health facility for care.

As high participation rates are essential, ZIMPHIA project partners are dedicating significant efforts to sensitize communities around Zimbabwe. The Ministry of Health and partners are working with traditional leaders, religious leaders, and local organizations to engage the community through educational brochures, advertising, radio spots, and even a song specially produced in collaboration with local Zimbabwean artists: Knock, Knock, Knock.

To prepare local teams to carry out the large-scale, very technical survey and to conduct the various blood tests, ICAP led the training of over 100 nurses, 15 medical laboratory scientists, and 40 interviewers. The ZIMPHIA team is also working with 12 district-level laboratories to ensure the medical tests are conducted correctly.

Over the past 30 years, Zimbabwe has made important strides in responding to the HIV epidemic. Through targeted HIV prevention efforts from voluntary medical male circumcision to the prevention of mother-to-child transmission of HIV, Zimbabwe has lowered its national HIV prevalence rate from 30 percent to less than 15 percent.

“Zimbabwe is at a turning point where an AIDS-free generation and an end to AIDS deaths is not only possible, but is in sight,” said Robert Scott, deputy chief of mission for the U.S. Embassy in Zimbabwe. “Not only will ZIMPHIA advance HIV insights, programming and policy in Zimbabwe, it will also serve as a template and example for other African countries that will conduct similar surveys in the coming years.”

ZIMPHIA is a Ministry of Health and Child Care initiative being implemented in partnership with National AIDS Council, ZIMSTAT, the U.S. Centers for Disease Control and Prevention (CDC), with support from the United States President’s Emergency Plan forAIDS Relief (PEPFAR). ICAP at Columbia University is the implementing agency for ZIMPHIA. Other ZIMPHIA partners include: Biomedical Research and Training Institute (BRTI), Lancet Laboratories, and Westat.